Focus Groups

Medicaid Incentives for Prevention of Chronic Diseases Evaluation

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1219 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10477 Focus Groups Form and Instruction
CMS-10477 Screener for focus group eligibility Attachment_4a_Focus Group_Screener_English_clean.docx Form and Instruction
CMS-10477 Discussion guide for focus groups Attachment_4b_Round_1_and_2_Discussion_Guide.pdf Form and Instruction
CMS-10477 Participant contact release form for focus groups Attachment_4d_Participant_Contact_Release_Forms_English_clean.docx Form and Instruction
CMS-10477 Focus group consent form Attachment_4e_Consent_Form_English_clean.docx Form and Instruction
CMS-10477 Screener_Spanish_new_clean Attachment_8a_Screener_Spanish_new_clean.docx Form and Instruction
CMS-10477 Participant_Contact_Release_Forms_Spanish_new_clean Attachment_8d_Participant_Contact_Release_Forms_Spanish_new_clean.docx Form and Instruction
CMS-10477 Consent_Forms_Spanish_new_clean Attachment_8e_Consent_Forms_Spanish_new_clean.docx Form and Instruction
Attachment_4f_Reminder_Email_English_clean.docx Focus group appointment reminder IC Document
Attachment_4c_Recruitment_Flyer_Template_English_clean.docx Focus group recruitment flyer IC Document
Attachment_8b_Discussion Guide_Spanish_new_clean.docx Attachment_8b_Discussion Guide_Spanish_new_clean IC Document
Attachment_8c_Recruitment_Flyer_Spanish_new_clean.docx Attachment_8c_Recruitment_Flyer_Spanish_new_clean IC Document
Attachment_8f_Reminder_Email_Spanish_new_clean.docx Attachment_8f_Reminder_Email_Spanish_new_clean IC Document

Information Collection (IC) Details

IC Title:	Focus Groups	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10477	Screener for focus group eligibility	Attachment_4a_Focus Group_Screener_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Participant contact release form for focus groups	Attachment_4d_Participant_Contact_Release_Forms_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Focus group consent form	Attachment_4e_Consent_Form_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Screener_Spanish_new_clean	Attachment_8a_Screener_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Participant_Contact_Release_Forms_Spanish_new_clean	Attachment_8d_Participant_Contact_Release_Forms_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Consent_Forms_Spanish_new_clean	Attachment_8e_Consent_Forms_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Discussion guide for focus groups	Attachment_4b_Round_1_and_2_Discussion_Guide.pdf	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 880	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	880	880
Annual IC Time Burden (Hours)	613	613
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Focus group appointment reminder	Attachment_4f_Reminder_Email_English_clean.docx	01/15/2014
Focus group recruitment flyer	Attachment_4c_Recruitment_Flyer_Template_English_clean.docx	01/15/2014
Attachment_8b_Discussion Guide_Spanish_new_clean	Attachment_8b_Discussion Guide_Spanish_new_clean.docx	01/15/2014
Attachment_8c_Recruitment_Flyer_Spanish_new_clean	Attachment_8c_Recruitment_Flyer_Spanish_new_clean.docx	01/15/2014
Attachment_8f_Reminder_Email_Spanish_new_clean	Attachment_8f_Reminder_Email_Spanish_new_clean.docx	01/15/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.